About The Position

The Transitional Care Clinic (TCC) program focus is on chronic disease management and readmission prevention for high-risk patients with heart failure (HF), chronic obstructive lung disease (COPD), and end stage renal disease (ESRD). TCC staff meet with inpatients at the bedside to provide chronic disease education, management, and care coordination for discharge and outpatient follow up. TCC staff work closely with multidisciplinary staff both inpatient and outpatient for optimal health management. Post discharge contact is provided through telephonic, video, and clinic follow-up. TCC staff evaluates and solve barriers around SDOHs identified. TCC Team includes RNs, NP, Pharmacist, CHW, SW, and Dietician.

Requirements

  • Nursing Diploma/Associate's in Nursing
  • RN License
  • <2 years of experience
  • No Supervisor Experience

Nice To Haves

  • 2 or more years experience as RN
  • Preferably with cardiac and/or pulmonary patients
  • EPIC documentation experience
  • Ability to collaborate, communicate, and problem solve
  • Bachelor's Degree in Nursing
  • 2-5 years of experience

Responsibilities

  • Assesses, coordinates, and evaluates each patient's plan of care.
  • Establishes, continuously evaluates, and documents an individualized discharge plan.
  • Ensures clinical documentation and cost-effective use of hospital resources.
  • Coordinates, negotiates, procures and manages the care of patients to facilitate achievement of quality cost-effective outcomes.
  • Works collaboratively with physicians and interdisciplinary staff, internal and external to the organization, to identify and resolve issues.
  • Performs and provides consultation regarding Utilization Management and Performance Improvement programs in order to obtain optimum value for the patient and the reimbursement source.

Benefits

  • Comprehensive medical, dental, vison, life insurance, and legal services available first day of the month after hire date
  • Disability insurance paid for by BJC
  • Annual 4% BJC Automatic Retirement Contribution
  • 401(k) plan with BJC match
  • Tuition Assistance available on first day
  • BJC Institute for Learning and Development
  • Health Care and Dependent Care Flexible Spending Accounts
  • Paid Time Off benefit combines vacation, sick days, holidays and personal time
  • Adoption assistance
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